Community Health Associate

About the Role

Community Health Workers are natural helpers who build trust with patients, connect them to health and social services, and support them in achieving health goals. They screen for social drivers of health such as food insecurity, housing, and behavioral health needs, helping patients set short-term goals to improve outcomes and access to care. This role requires strong communication, cultural sensitivity, and a passion for community health.

Key Responsibilities

• 60% - Direct in-person and telephonic patient outreach
• 30% - Documentation
• 10% - Meetings, program development

Job Functions

• Work in collaboration with a multidisciplinary team of clinicians as part of the Care Coordination program to provide high quality, outcome-based, patient-centered care.
• Assist high-risk patients address social barriers to care, ensure sustainable connections to health care services, providers, and social supports.
• Participate in the AHS CHW training program and onboarding curriculum.
• Follow departmental policies, procedures, processes, and professional and care standards.
• Regularly attend and actively participate in assigned intradisciplinary and interdisciplinary meetings, team meetings, supervisory sessions, and in-service training.
• Engage in proactive community outreach efforts to identify individuals who may benefit from health services and programs.
• Ensure timely response to referrals and adhere to evidence-based care models.
• Maintain documentation and performance metrics according to departmental processes and standards.
• Empower and motivate patients toward self-efficacy, making patient-centered changes in behavior and lifestyle.
• Meet patients in a medical office, hospital, home, or community setting to conduct a guided interview and complete a full SDOH screening.
• Partner with patients to set patient-driven goals for their health and the steps to achieve them.
• Focus on building rapport, motivational interviewing, effective listening, cultural sensitivity, and setting goals and expectations.
• Make weekly follow-up calls and home visits to patients.
• Connect patients with community resources to help with social issues like homelessness, substance abuse, and hunger.
• Assist patients with enrollment in medical, social, and financial programs and benefits for which they are eligible.
• Promote education on preventative healthcare measures, disease management, and healthy lifestyle choices.
• Assist patients with navigating the healthcare system and accessing medical services.
• Maintain a current knowledge base of community agencies and key contacts.
• Assist with patient advocacy, navigation, and engagement with sustainable medical, social, insurance, and benefit systems.
• Collaborate with healthcare professionals, social service agencies, and community organizations.
• Ensure ongoing collaboration and communication with the larger interdisciplinary Care Coordination team and providers.
• Maintain accurate and up-to-date documentation of all interactions, services provided, and outcomes achieved.
• Document each patient encounter in detail and prepare reports and documents as needed or requested.
• Provide patient-specific and caseload updates to supervising social worker and/or manager on a regular basis.

Requirements & Tech Stack

• High School diploma or GED required.
• Long-time resident of or familiarity with a community in the role’s service area and good knowledge of the community’s challenges and resources.
• Valid NJ Driver’s License.

Qualifications

• Higher educational degree a plus.
• Prior experience as an outreach worker or customer-service experience a plus.
• Knowledge of community resources and social service, financial, insurance, and advocacy systems a plus.
• Bilingual in Spanish is a plus.